PURPOSE: During admission case review, teams work to develop a shared understanding of the problems they need to address during the patient's hospitalization. However, research on the effects of the case review on patient care is limited. Informed by rhetorical genre theory, the authors explored the impact of team's communication practices on the comprehensiveness of the case review. METHOD: Using a multiple-case-study approach, the authors in 2010 observed in person, audio-recorded, and transcribed data from overnight and morning case review discussions for 19 patient cases in the internal medicine department of an academic medical center. They also extracted data from the corresponding admission notes. They used a constant-comparison approach to identify emerging themes within and across cases. RESULTS: The authors identified detours, which typically arose from supervisors' interruptions, in all 19 cases. They identified five detour types: pausing the presentation, referring to a section later in the presentation, presenting sections out of sequence, skipping a section, and truncating the presentation. Although supervisors' interruptions during case review discussions allowed for teaching and patient care, they also created detours from the usual case presentation, which then could lead to the omission of relevant case details. CONCLUSIONS: Supervisors' interruptions during case review discussions can lead to detours, which simultaneously afford valuable opportunities for teaching and threaten comprehensive information sharing. Future research should explore detours in other teaching settings to better understand their positive, negative, and unintended consequences for patient care.

Dr. Goldszmidt is associate professor, Division of General Internal Medicine, Department of Medicine, University of Western Ontario, Schulich School of Medicine and Dentistry, London, Ontario, Canada. He is also associate director, Centre for Education and Research, London, Ontario, Canada. Ms. Aziz is a second-year medical student, University of Western Ontario, Schulich School of Medicine and Dentistry, London, Ontario, Canada. Dr. Lingard is professor of medicine and adjunct professor, Department of Family Medicine, University of Western Ontario, Schulich School of Medicine and Dentistry, London, Ontario, Canada. She is also senior scientist and director, Centre for Education and Research, London, Ontario, Canada.